Solving barriers to life-saving care in community health programs during COVID-19
How a collaborative design sprint process helped us develop an innovative digital solution for community health workers to deliver quality care during COVID-19.
The International Rescue Committee (IRC) works with a network of about 15,000 community health workers in over 25 countries around the world. Community health workers are typically volunteers associated with the local healthcare system and reside in or near the communities they serve.
Although none have formal training, community health workers are often the first line of defense against child deaths from preventable and easily treatable diseases, particularly in remote communities where formal health facilities are inaccessible. Their task is to share information and sometimes provide integrated community case management services (iCCM) to diagnose and treat the most common causes of death in children under five: diarrhea, malaria, and pneumonia. They typically receive monthly supervision visits from health center staff. Community health workers are also trusted members of their communities, bridging the gap between health facility personnel and community members by fostering credibility through their status in the community.
With the advent of COVID-19, community health workers have become even more critical to ensuring continuity of care, as health facilities may be overwhelmed with COVID-19 cases and may want to limit the numbers of community members attending clinics for other services. As part of the IRC’s commitment to delivering quality healthcare, we are continually adapting our services to respond to the pandemic, while still providing essential health care services to refugees and displaced people.
A group of technical health experts, designers, and program staff from the IRC came together remotely to conduct a design sprint focused on Liberia. A design sprint is an intensive client-centered process that can help us rapidly understand, design and test breakthrough solutions in a limited amount of time. The objective of this sprint was to identify barriers that prevent community health workers from safely and effectively delivering life-saving services during the pandemic (and beyond) and identify solutions to overcome those barriers. We looked at big picture systemic issues that pose problems in community health programs all around the world: supervision, supply chain, training, tools adapted for low-literate workers and motivation/retention.
The challenges community health workers face
Although community health workers can be an extremely effective means of reaching last-mile communities, they still rely on the expertise of supervisors to oversee their work and build their capacity. The risks of inadequate supervision are high: misdiagnosis, insufficient follow-up, and neglecting to follow COVID-19 protocols can lead to improper treatment of life-threatening illnesses and spread of infection. According to UNICEF and the WHO, “irregular or inadequate supervision is almost universally cited as a key problem in [community health worker] programmes. Regular supervision has been associated with better project outcomes and more accurate classification and treatment of childhood illness by [community health workers].”
As a group we honed in on the supervision of community health workers, particularly during the global pandemic, as a critical area that needs to be improved to ensure that they can continue to deliver life-saving services.
Community health workers are often located far from their supervisors who must travel long distances to conduct visits. Oftentimes these supervision visits don’t happen as frequently as they are supposed to for a myriad of reasons, including lack of transport, overwhelming clinical workload at the health facility, insecurity, and significant environmental conditions: during the rainy season, some villages in Sub-Saharan Africa are inaccessible for months. In addition, most supervision visits often focus on administrative matters instead of focusing on practical skills, such as direct observation of sick child consultations and coaching them to improve the quality of care.
COVID-19 has made it essential for community health workers to receive timely updates on changes to safety protocols (i.e. no touch iCCM), key prevention messages and social distancing measures, without necessarily bringing them together for a formal training. They may be asked to provide contact tracing services or follow-up with mild suspected COVID-19 cases and need access to timely information.
Community health workers will also need access to up-to-date information about infection prevention and control practices, including how to properly use personal protective equipment as per the Ministry of Health policy, to protect themselves as well as the communities they are serving to prevent the spread of COVID-19.
A solution that enables frequent remote feedback
The IRC Liberia team helped facilitate interviews with community health workers, their supervisors, and the county coordinators so the team was able to understand each group’s experiences, what motivates them, and how they interact with existing technology. This allowed us to identify pain-points, resourcing challenges, and other issues that have implications for the quality of care delivered in the community through community health workers. After several rounds of feedback with clients, we decided to move forward with prototyping an open-source mobile application called Dela.
Dela aims to be an application that uses audio and video features to support more frequent feedback between community health workers and their supervisors, improving quality care in remote off-grid contexts, and allowing them to receive remote supervision. The app would work offline to enable community health workers to capture video and audio of their consultations with sick children, where it is then sent on to their supervisors, who can provide feedback and advice based upon what they’ve seen in the video. Supervisors can also share instructional videos on how to perform essential skills that they see the community health worker may need to review. The easy-to-use app will be designed to work with limited access to phone service, and with limited digital literacy skills by using voice-over functionality.
We believe that Dela has the potential to solve three key supervision challenges in community-based health delivery systems.
1. Insufficient follow-up
Community health workers usually receive a one-off training that covers an enormous amount of content and they don’t often receive refreshers to help them retain knowledge or learn new skills. This is why supervision visits focusing on quality of services delivered is critical.
Dela can help supervisors use performance data to identify gaps in a community health worker’s basic training and send prerecorded and existing content to help workers retain, refresh, and improve their skills.
Example:
Through the app, a supervisor would be able to send an instructional video or Ministry of Health job aid to a community health worker who has been having trouble remembering how to properly check for danger signs such as chest in-drawing, a sign of severe pneumonia.2. Limited ability to course correct
Supervisors can’t easily monitor community health workers remotely. In-person visits can be challenging due to access issues, from administrative to insecurity, and often don’t allow enough time for direct observation. Community health workers often operate for long periods of time without consultations and advice from their supervisors and may feel isolated.
Dela would enable more consistent communication between community health workers and supervisors through video messages so supervisors can observe actual household visits. This means supervisors can catch and resolve issues early and improve the quality of services delivered.
Example:
A community health worker sends a video recording to their supervisor documenting them administering a malaria rapid test to a child. The supervisor notes they failed to implement new COVID-19 “no-touch” protocols and immediately sends a voice note alerting the community health worker.3. Community health worker performance is often not tracked or recognized. This lifesaving work is often invisible to those outside their local community and professional development opportunities aren’t always possible. This can be de-motivating and lead to lower quality of service over time
Dela tracks individual community health worker performance over time, acknowledges progress, and showcases their accomplishments to themselves and their supervisors. This allows their supervisors to focus their attention on areas of improvement and gives community health workers positive reinforcement for their work. The app would include a dashboard that tracks progress and achievements, as well as a customizable profile for each community health worker.
Example:
Profiles display progress towards 5-star ratings across different performance metrics and use motivating, gamified rewards (like unlocking features to upgrade your avatar) to keep them engaged and ensure the app is fun to use.Prototyping the next iteration
We have received very positive feedback from both community health workers and their supervisors in Liberia, where initial prototyping took place. As one health worker stated, “Seeing the video would help my supervisor provide feedback. It’s better for him to see what is happening.”
Another supervisor who is responsible for 17 people noted that, “I have many [community health workers] and may not be able to see them all and the video will help me see what they are correctly and incorrectly doing even when I’m not there.”
We have formed partnerships with Medic Mobile and Think-It to prototype and test the Dela concept with community health workers and their supervisors in both Liberia and the Democratic Republic of Congo to see how we can maximize their experience and incentivize long-term use. We feel it is important to prototype and test in two different contexts to develop an application that is relevant in a multitude of contexts. For example, there are challenges in connectivity, data transfers of video and costs of data transfers we need to overcome. We are also aware that video may not be possible in some settings and we are exploring other solutions for remote supervision, including Interactive Voice Response systems and chat bots.
If Dela is found to be a viable application, it would revolutionize how community health worker supervisions are conducted, making workers feel more supported and motivated and improving the quality of care delivered to communities over time.
Authored by: Alison Wittcoff, Technical Health Advisor at the IRC
